International Urogynecology Journal

https://doi.org/10.1007/s00192-019-03882-4

ORIGINAL ARTICLE

Birthweight and pelvic floor trauma after vaginal childbirth

Natalia Martinho 1 & Talia Friedman 2 & Friyan Turel 2 & Kirsty Robledo 3 & Cassio Riccetto 1 & Hans Peter Dietz 2,4

Received: 6 November 2018 / Accepted: 15 January 2019

# The International Urogynecological Association 2019

Abstract
Introduction and hypothesis Birthweight seems to be a risk factor for levator ani muscle (LAM) avulsion and a predictive factor
for pelvic organ prolapse (POP). Most trauma seems due to first vaginal birth.
Methods One thousand one hundred twenty-five women with at least two vaginal deliveries underwent a physician-directed
interview, followed by clinical examination (digital palpation and Pelvic Organ Prolapse Quantification-POPQ) and 4D
translabial ultrasound. Ultrasound volume data were obtained at rest, on pelvic floor contraction and Valsalva. The investigator,
blinded to all other data, performed offline analysis of the LAM integrity and hiatal area on Valsalva. We tested for associations
between birthweight of the first and of the largest vaginally born baby on the one hand and avulsion and symptoms/signs of
prolapse on the other hand.
Results Between July 2014 and July 2017, 1575 patients were seen. After exclusion of nulliparae and women with just one
vaginal birth, 1202 remained. Another 77 were excluded due to missing data, leaving 1125. A significant association was found
between birthweight and LAM avulsion as well as significant prolapse on POPQ. The birthweight of the first vaginally born baby
was at least as predictive for avulsion as the birthweight of any subsequent births, even when adjusted for maternal age at first
delivery and use of forceps.
Conclusions The birthweight of the first vaginally born baby is associated with levator avulsion and subsequent POP. Maximum
weight of vaginal births does not seem to be a stronger predictor.

Keywords Birthtrauma . Birthweight . Levator ani muscle avulsion . Pelvic floor . Pelvic organ prolapse . Ultrasound

Introduction exerted by the passage of the fetal head, which is enhanced

by maternal pushing [5, 6]. Such stretch, which is clearly more
Vaginal childbirth is the primary environmental factor in the than what can be tolerated by normal skeletal muscle [5], may
etiology of female pelvic organ prolapse (POP), at least partly lead to injuries of the levator ani muscle in some women,
mediated by trauma to the levator ani muscle [1–4]. During ranging from irreversible hyperdistension of the levator hiatus
the second stage of labor, the pelvic floor muscles undergo a (microtrauma) to avulsion (macrotrauma) [7, 8].
remarkable degree of soft tissue stretch due to the pressure Levator ani muscle avulsion is characterized by a complete
traumatic detachment of the puborectalis muscle from its in-
Presentation at a conference/meeting This work was presented at the sertion to the inferior pubic ramus [7, 8]. This trauma is asso-
IUGA 43rd Annual Meeting, Vienna, Austria, from June 27 to 30, 2018. ciated with pelvic organ prolapse [1–4] and its recurrence after
reconstructive surgery [9].
* Hans Peter Dietz Major risk factors of levator trauma are first vaginal deliv-
hpdietz@bigpond.com ery [10, 11], advanced maternal age at first delivery (>
35 years) [12] and use of forceps [13]. It is suggested that
1
Faculty of Medical Sciences, State University of Campinas –
UNICAMP, Campinas, Brazil birthweight may also be a risk factor for levator trauma [14]
2 and a predictor for prolapse stage and symptoms [15]. It is
Sydney Medical School Nepean, University of Sydney,
Sydney, Australia however not clear whether it is the weight of the firstborn or
3 the weight of the heaviest baby that is more important for the
NHMRC Clinical Trials Centre, University of Sydney,
Sydney, Australia etiology of levator trauma. Thus, we tested for associations
4 between birthweight of the first and of the largest vaginally
Sydney Medical School Nepean, Nepean Hospital,
Penrith, NSW 2750, Australia born baby on the one hand and avulsion and symptoms/signs

of prolapse on the other. Our study aimed to test the hypoth-
esis: ‘The birthweight of the heaviest vaginally born baby has
a stronger association with LAM avulsion than the
birthweight of the first vaginal birth.’
Materials and methods
Design, setting and participants
This was a retrospective study involving ultrasound data sets
of 1125 vaginally parous women seen routinely at two tertiary
urogynecological centers between July 2014 and July 2017.
Our inclusion criteria were women who had had at least two
vaginal childbirths. Women who had no information regard-
ing their babies’ birthweight were excluded. This study was
approved by the local Human Research Ethics Committee
(NBMLHD HREC 13–70).
Outcome measures
Personal, clinical and obstetric data
All women underwent a standardized clinical assessment
which included a physician-directed interview and patient-
reported personal, clinical and obstetric data. The following
characteristics were investigated: age, body mass index, pari-
ty, delivery mode, birthweight, previous surgical history and
presence of urinary and POP symptoms. The average time
span between the birth of the first child and the assessment
was 33.4 (range, 0.7–69.7) years. We did not obtain informa-
tion on the timing of subsequent births. All reported personal,
clinical and obstetric data were obtained on the same day.
Pelvic floor assessment
Digital palpation was performed to assess PFM contractility,
which was graded according to the Modified Oxford Grading
scale (range 0 to 5) [16]. POP was quantified for each com-
partment separately (anterior, middle, posterior) using the
Pelvic Organ Prolapse Quantification (POPQ) system (range
from stage 0 to 4) [17]. POPQ stage 2 or higher for anterior
and posterior vaginal wall as well as POPQ stage I or higher
for the uterus were considered clinically relevant and classi-
fied as a significant prolapse on POPQ [18].
Following this, 4D translabial ultrasound (TLUS) was per-
formed with women in the supine position, after voiding,
using a GE Voluson 730 Expert system (GE Medical, Kretz,
Austria) with an 8–4 MHz curved array volume transducer.
Volume acquisition was performed with an acquisition angle
of 85 degrees, at rest, on pelvic floor muscle (PFM) contrac-
tion and maximum Valsalva [19].
Int Urogynecol J
Ultrasound data analysis
Offline analysis of ultrasound volume data sets was performed
using the 4D View 10.0 software (GE Medical Ultrasound,
Ryde NSW, Australia) by the first author, blinded to all other
data, 3 months to 3 years after the imaging volume data had
been obtained and stored. A test-retest series performed prior
to commencing measurements for the study yielded a coeffi-
cient of Kappa’s agreement of 0.875 between the first and last
author, showing good agreement for the diagnosis of avulsion.
Levator ani muscle integrity was evaluated using tomo-
graphic ultrasound imaging (TUI) of volumes obtained on
maximum PFM contraction. Eight slices were obtained in
the axial plane at 2.5-mm slice intervals, from 5 mm below
to 12.5 mm above the plane of minimal hiatal dimensions
[20]. A complete levator avulsion was diagnosed if at least
the three central slices (i.e. the plane of minimal dimension
plus slices 2.5 mm and 5 mm cranial to this plane—slices 3 to
5) showed an abnormal muscle insertion on the inferior pubic
ramus [21], as shown in Fig. 1.
Hiatal area was measured at the plane of minimal hiatal
dimensions, defined in the midsagittal plane as the minimal
distance between the symphysis pubis and the anterior margin
of the central aspect of the puborectalis muscle [22].
Statistical analysis
Statistical analysis was performed by the NHMRC Clinical
Trials Centre of the University of Sydney using the program
SPSS (Statistical Package for the Social Sciences) and
adopting a significance level of 5% (p < 0.05). We tested for
association between birthweight of the first vaginally born
baby and maximum birthweight of any vaginally born baby
with symptoms and signs of POP and levator avulsion, using
two sample t-tests and Pearson’s correlation. Univariate and
multivariate logistic regressions were used to quantify the
contribution of each of these birthweight variables on levator
avulsion. Multivariate analyses were adjusted for maternal age
at first delivery and use of forceps, with each model’s perfor-
mance estimated with the area under the receiver-operator
characteristic (ROC) curve. The difference between two areas
under the ROC curves was analyzed as described by DeLong
and collaborators (1988) [23] to test the hypothesis: ‘The
maximum weight of any vaginally born baby is a stronger
predictor for avulsion compared to the birthweight of the first
vaginal birth.’
Results
Between July 2014 and July 2017, 1575 consecutive patients
were seen at two tertiary urogynecological centers. Of those,
23 had missing ultrasound volumes, 373 were nulliparous or
Int Urogynecol J
Fig. 1 Right-sided complete
avulsion, indicated by an asterisk
(*). A complete levator avulsion
is diagnosed if at least the three
central slices (slices 3 to 5) show
an abnormal muscle insertion on
the inferior pubic ramus
had just one vaginal delivery, and 54 did not have data regard-
ing their babies’ birthweights and were excluded from the
study. Therefore, the final sample was composed of 1125 par-
ous women, and all reported data pertain to this population
unless otherwise indicated.
Mean age was 57.1 ± 12.5 years old (range 24.2 to 89.7),
and mean body mass index was 29.5 ± 6.3 kg/m2 (range 15.7
to 58.8). All patients were parous women who had had at least
two vaginal births and 371 (33%) at least one forceps delivery.
The mean birthweight of the first vaginally born baby was
3362 g (range, 459–5000 g); the average weight of the heavi-
est vaginally born child was 3775 g (range, 1786–5900 g).
Three hundred ninety-four (35%) had had a hysterectomy
since their last birth, 144 (12.8%) incontinence surgery and
236 (21%) prolapse surgery. Eight hundred eighteen (72.7%)
reported symptoms of stress incontinence, 842 (74.8%) of
urge incontinence, 289 (25.7%) of increased urinary frequen-
cy, 433 (38.5%) of nocturia and 374 (33.2%) of voiding
dysfunction.
Clinical examination was possible in 1124 women. On
POPQ examination (Table 1), 693 (61.6%) had a significant
cystocele, 220 (37.5%) significant uterine prolapse and 646
(52.8%) significant descent of the posterior vaginal wall. The
Gh + Pb measure was abnormal (≥ 7 cm) [24] in 905 women
(80%). The Modified Oxford Scale was used to grade the
pelvic floor muscle contractility, resulting in a mean grading
of 2.1 (range 0–5) on the right and 2.3 (range 0–5) on the left.
On digital palpation, a unilateral avulsion was found in 170
women (15.1%) while bilateral avulsion was found in 128
women (11.4%).
During Valsalva, the mean hiatal area was 29.8 cm2 (SD
9.7). Complete levator avulsion was found in 293 women
(26%), and it was bilateral in 134 (11.9%). Table 2 shows
the association between the birthweight of the first vaginally
born baby and the maximum weight of any vaginally born
baby with levator avulsion and symptoms and signs of pro-
lapse. There was no significant difference in birthweight re-
garding the type of avulsion (uni- or bilateral) on subgroup
analysis.
Subsequent births were heavier than the first in 456/1125
(40.5%). These women did not have a higher risk of avulsion
than those with smaller subsequent births. The odds for leva-
tor ani muscle avulsion are 1.36 times greater for those women
in whom the first baby was the heaviest compared with those
who had a heavier baby in a subsequent delivery, even when
adjusted for maternal age at first delivery and use of forceps
(p = 0.03) (Table 3).
The birthweight of the first vaginally born baby is a
better univariate predictor for levator avulsion (AUC =
0.574) compared with the maximum weight of any vagi-
nally born baby (AUC = 0.540). We created two models for
the prediction of avulsion, containing known predictors
such as forceps and age at first birth, and then added either
the birthweight of the firstborn or the birthweight of the
heaviest baby. When adjusted for maternal age at first de-
livery and use of forceps, the area under the curve (AUC)
for the birthweight of the first vaginally born baby was
0.634 (model 1) and the AUC for the maximum weight
of any vaginally born baby was 0.628 (model 2). This
difference was not significant (p = 0.473). Hence, we were
 Int Urogynecol J

Table 1 Clinical examination of pelvic organs descent
Mean ± SD (range)
(in centimeters)
Pelvic Organ Prolapse Ba −0.6 ± 1.6 (−3 to 7.5)
Quantification-POPQ n = 1124 C −4.2 ± 2.9 (−11 to 8)
Bp −0.9 ± 1.3 (−3 to 8)
Gh 4.5 ± 1.2 (1.5 to 10)
Pb 3.4 ± 0.8 (1 to 7)
Data are presented as mean and standard deviation (SD)
not able to prove our hypothesis (‘the birthweight of any
vaginally born baby is a stronger predictor for avulsion
compared to the birthweight of the first vaginal birth’).
Discussion
This study has demonstrated a significant relationship be-
tween birthweight and major levator trauma (levator avulsion)
as well as significant prolapse on POPQ in women presenting
for treatment of pelvic floor dysfunction over 30 years after a
first vaginal birth. The birthweight of the first vaginally born
baby was at least as predictive for levator avulsion as the
maximum weight of any subsequent vaginally born baby, re-
futing our hypothesis.
The first vaginal delivery seems to be the crucial moment
for levator trauma [10, 11], which occurs in approximately
10–35% of women giving birth vaginally in the developed
world [8], although trauma rates may be substantially lower
in populations with traditional reproductive behavior [25].
Additional pregnancies and vaginal births do not seem to be
associated with a significant increase in the odds of levator
avulsion [10].
The baby’s birthweight is strongly associated with head
circumference (r = 0,749; p < 0.001) [26] and therefore is
closely linked to the degree of stretching of the puborectalis
muscle during vaginal delivery [27]. It is not surprising there-
fore that larger head circumference seems to be associated
with increased length of the second stage of labor [26].
In this study, if the first vaginally born baby was also the
heaviest one, this was found to be a significant risk factor for
levator avulsion with an odds ratio of 1.36 (p = 0.03). Even
when adjusted for maternal age at first delivery and use of
forceps, the association between first birthweight and avulsion
remained significant (AUC = 0.634) although not significant-
ly stronger than the maximum weight of any vaginally born
baby (AUC = 0.628).
It is plausible that tissues that are unable to stretch with a
given distension because of the individual biomechanical prop-
erties of the mother will rupture at the time of a first birth.
Biomechanical properties clearly vary enormously. [27]. The
second birth will be easier because the rupture has already
occurred with the first, and further trauma may then be unlikely.
On the other hand, if tissues survived intact the first time, they
probably will not rupture at the time of a second birth. This is
consistent with evidence from observational studies [10, 11].
Current literature is contradictory regarding the association
between birthweight and obstetric trauma and the predisposi-
tion to POP occurrence [28, 29]. Delivery of infants over
4000 g seems associated with Obstetric Anal Sphincter
Injury (OASIS) [30] and pelvic floor dysfunction [31].
Valsky and collaborators (2009) [26] showed that, for
birthweight > 3400 g, the odds of levator avulsion increased
by a factor of 1.094 (p = 0.028) for every 100 g increase.

Table 2 Association between birthweight and levator avulsion and signs and symptoms of prolapse

Birthweight of the first Maximum weight of any

vaginally born baby (g) vaginally born baby (g)

Symptoms of prolapse (mean ± SD)1 Yes (n = 619) 3377 (± 0.563) vs 3343 (± 0.578) p = 0.33 3693 (± 0.557) vs 3696 (± 0.562) p = 0.91
No (n = 506)
Significant prolapse on POPQ (M ± SD)1 Yes (n = 919) 3377 (± 0.568) vs 3292 (± 0.573) p = 0.05 3711 (± 0.571) vs 3618 (± 0.495) p = 0.03
No (n = 205)
Levator ani muscle avulsion1§ Yes (n = 293) 3467 (± 0.553) vs 3324 (± 0.571) p < 0.001 3755 (± 0.536) vs 3673 (± 0.565) p = 0.03
No (n = 832)
Hiatal area on Valsalva (n = 1124)2 p < 0.001; r = 0.13 p < 0.001; r = 0.15

Data are presented as mean and standard deviation (SD)

§
Considering complete unilateral (right or left) or bilateral avulsion
POPQ = Pelvic Organ Prolapse Quantification
1
t-test was used. 2 Pearson’s correlation test was used
Int Urogynecol J
Table 3 Birthweight and risk of levator ani muscle avulsion
First baby Any other p OR 95% CI
heaviest subsequent value1
n = 669 birth heaviest
n = 456
Avulsion No 511 (76.4%) 321 (70.4%) 0.03 1.36 1.04–1.78
Yes 158 (23.6%) 135 (29.6%)
1
Chi-square test; OR: odds ratio; 95% CI: 95% confidence interval. n = 1125
Several limitations of our study need to be mentioned.
Obstetric data, including birthweight, were patient-reported,
and this may have led to recall bias. This is particularly true
in view of the fact that the average time span between the birth
of the first child and the assessment was 33.4 (range, 0.7–
69.7) years.
In addition, we did not have information on some char-
acteristics of labor that may also influence the likelihood
of levator ani trauma and act as confounders, such as
length of the second stage of labor, fetal head circumfer-
ence, malposition or the occurrence of obstructed labor.
Moreover, due to the above-mentioned long latency of
33.4 years, our findings clearly represent past rather than
present obstetric practice, which may also have influenced
results. Due to this long latency, other factors such as
chronic constipation, smoking, asthma and menopause
may have influenced our findings. However, menopausal
status seems unlikely to impact pelvic floor functional
biometry [32], and the same seems true for asthma and
smoking (unpublished own data).
Finally, it needs to be mentioned that the majority of our
patients were Caucasian and symptomatic of pelvic floor dys-
function, limiting the validity of our findings for other
populations.
In conclusion, birthweight is significantly associated with
levator avulsion and subsequent pelvic organ prolapse, espe-
cially the birthweight of the first vaginally born baby.
Maximum birthweight is also predictive, but clearly not more
so than the weight of the first vaginally born child.
Funding The first author was the recipient of a scholarship sponsored by
the Foundation of Research Support of the State of Sao Paulo, Brazil
(FAPESP process 2015/22521–8 and 2017/02565–6) during her visit at
the Pelvic Floor Unit, Nepean Hospital, University of Sydney, Australia.
Compliance with ethical standards
Conflicts of interest HP Dietz has received paid travel expenses and
honoraria from GE Medical.
Publisher’s note Springer Nature remains neutral with regard to jurisdic-
tional claims in published maps and institutional affiliations.
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